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Application <br />- FOR - <br />- Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax 574-235-9578 • Email: historic@michiana.org <br />Website: http://cwmmunitymichiana.org/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received .YiDg�&L 0100 7 Application Number!9 DO 7 - 0434A <br />Past Reviews: r-1 YES (Date ofLast Review) <br />Staff Approval authorized by: <br />[] NO <br />Title: <br />Historic Commission Review Date: .�f ai I " a 0a 7 <br />or <br />Local Landmark 2ir-ocal Historic District (Name) G • �' <br />National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: <br />E] Denied ❑ Tabled E] Sent To Committee ❑ Approved and Issued <br />DATE � <br />Address of Property for proposed work: <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) r `.. #�' '+:R t� g'"p""° �• <br />a -5 '^Aq <br />M'= <br />Address of Property Owner(s): Jt, W'I�� <br />Contractor(s) Name: I u t t - 1.i ') r-:; A r! r rt 1 i13 -. t J ' <br />Contract Company Name: A-ref a f / . ."t; :' .a a s e ° t 'XII <br />Contractor Address: <br />r �. ;'yy �. � �.. �;,.yl r',9 , ,�`' �•r ,j.:F� '��' .Y•'6 ,ie..w� <br />City. • :. aKPhone: <br />...� <br />Current Use of Building: <br />(Single Family - Multi -Fancily - Commercial - Government - Industrial - Vacant -etc.) <br />Type of Building Construction: &iA,. <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: In-kind Landscape New Ej Replacement (not in-kind) F] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />'31:r ;.�G ''Y �. r rt � ¢ '�+ P � �4 Y`s.�k.k an>•c �.�`N=�, v <br />w�iS tr`�yp rl 43 <br />Owner/Contractor. Fax: e-mail '.'r,�rS•:::;+Y <br />(This office will correspond udth only one designee) <br />and/or <br />Signature of Owner Signature of Contractorf <br />— APPLICATION REQ IRREMENTS ARE LISTED ON REVERSE SIDE — <br />